Provider Demographics
NPI:1720184708
Name:JIMENEZ, GONZALO (LCSW)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 S 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-6533
Mailing Address - Country:US
Mailing Address - Phone:956-289-7000
Mailing Address - Fax:956-289-7257
Practice Address - Street 1:1901 S 24TH AVE
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-6533
Practice Address - Country:US
Practice Address - Phone:956-289-7000
Practice Address - Fax:956-289-7257
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX015421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R945OtherMEDICARE
TX138708611Medicaid
TX138708613Medicaid
TX138708611Medicaid